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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 09),953-7697 FOR INSPEC77ONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Com✓ 16-C -- CITY/MI; k C Vs CROSS STREET tvOd4J 6JI , APN D/ oV, PARCEL-..--SIZE --iI!�.. i ----- �( {{-- -2q7- 0 /��J q OWNER NAME___/u, C l _ 1-,Cf, -2q7— g7iu�Q OWNER ADDRESS 3 "' � 4SC $ _— ---�— CITY/STATE21P 1'C+/ CONTRACTOR 0!'�`C 4 AI C �/ _____, ___ PHONE 3 `/_3'IY CONTRACTOR ADDRESS a �-IS Ls 'v c.___ _ CffY/$TATFIZM a I ` LICENSE 11nC-42 1111C-36 OTHER z_ NUMBERLI,/Y25,� EXPIRATIONDATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y [ l 1 PERC TEST #____ rPERMIT#_ _ LAND USE APPLICATION# BUILDING _ TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED ALTERNATN I REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION fINSTALLATION WILL SERVE: U RESIDENCE I I COMMERCIAL ❑ OTHER___ NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG _ CAPACITY gal If OF COMPARTMENTS_.____ ❑ GREASETRAP TYPE/MFG _ CAPACITY _ _ gal #OF COMPARTMENTS_ DISTANCE TO NEAREST: WELL It FOUNDATION it PROPERTY LINE h ❑ LIFT STATION SIZE TYPE OF PUMP _❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS _______. . #OF LINES LENGTH OF LINES It DISTANCE TO NEAREST WELL __ fl FOUNDATION it PROPERTY LINE It ❑ FILTER BED WIDTH _.__— R LENGTH_ ft DEPTH _ —_ _—it DISTANCE TO NEAREST WELL _ it FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH_ ft LENGTH It DEPTH It DISTANCE To NEAREST WELL it FOUNDATION-, _h PROPERTY LINE_ ft ❑ SUMPS WIDTH____ it LENGTH _It DEPTH It DISTANCE TO NEAREST WELL it FOUNDATION _ _it PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH It DISTANCE TO NEAREST WELL__ it FOUNDATION it PROPERTY LINE it ❑ SEEPAGE PITS NUMBER _ WIDTH_ __ it DEPTH _It DISTANCE TO NEAREST WELL It FOUNDATION _ ..._-It PROPERTY LINE R I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WTTH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMOV4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 2 97 SIGNED _. TIC C D IVIV'e- A# SAN O fa I 21 DE RTME T SE O LY Application Accept _ Date �D _� Area _�Y.`— _ Employee ID# S�� Final Inspection By Date_ U SPECIAL PERMIT-Approved by Character of Soil to De of 3 Ft: _ _ PIU ump Soil Character: COMMENTS_ b D v w ra,:A1 PE SC Received k Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitte Service Request# i-Z o 7 �� Z t O 14 52 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4207 ,:?4,A?